Job Description

　　Job Summary

　　Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

　　** Based in New Mexico

　　Knowledge/Skills/Abilities

　　• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

　　• Reviews quality referred issues, focused reviews and recommends corrective actions.

　　• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

　　• Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.

　　• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

　　• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.

　　• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

　　• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

　　• Develops and implements plan medical policies.

　　• Provides implementation support for Quality Improvement activities.

　　• Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed.

　　• Works with Contracting Department in contract negotiation.

　　• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.

　　• Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.

　　• Actively participates in regulatory, professional and community activities.

　　Job Qualifications

　　REQUIRED EDUCATION:

　　• Board Certified (ANP) specializing in Behavioral Health

　　REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

　　• 5 yrs clinical practice specializing in Behavioral Health (Mental Health and Substance Abuse) in the state of New Mexico.

　　• 3 years experience in Utilization/Quality Program management.

　　• 2+ years HMO/Managed Care experience.

　　• Current clinical knowledge.

　　• Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

　　• Knowledge of applicable state, federal and third party regulations

　　REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

　　Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.

　　PREFERRED EDUCATION:

　　Master’s in Business Administration, Public Health, Healthcare Administration, etc.

　　PREFERRED EXPERIENCE:

　　• Peer Review, medical policy/procedure development, provider contracting experience.

　　Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

　　PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

　　Board Certification (Primary Care preferred).

　　PHYSICAL DEMANDS:

　　Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

　　To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

　　Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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　　Pay Range: $105,958.12 - $229,575.94 / ANNUAL

　　*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.